Opportunistic Infections

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Prevention of Secondary Disease: Preventive Medicine

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Updated November 2006

III. Opportunistic Infections

Recommendation:

Clinicians should initiate prophylaxis for specific opportunistic infections as indicated in Table 1 and discontinue prophylaxis as indicated in Table 2.

Prevention of opportunistic infections remains a critical aspect of HIV care and treatment. The probability of a patient acquiring an HIV-associated OI can be determined by reviewing the following: 1) the patient’s CD4 cell counts, 2) primary and secondary prophylaxis therapies, and 3) patient’s adherence to ARV therapy.

For more information on management of opportunistic infections, refer to the Infectious Complications Associated With HIV Infection guidelines developed by the Medical Care Criteria Committee. Available at: www.hivguidelines.org.

Table 1: Initiation of Primary OI Prophylaxis

Pathogen	Initiate Prophylaxis	Preferred Agent	Alternative Agents
Pneumocystis jirovecii pneumonia*	CD4 <200 cells/mm³ or <14%, or a history of oropharyngeal candidiasis	TMP/SMX qd or 3x/wk	Dapsone† Dapsone† + pyrimethamine + leucovorin Atovaquone Aerosolized pentamidine
Mycobacterium avium complex (MAC)	CD4 <50 cells/mm³	Azithromycin Clarithromycin	Rifabutin Azithromycin + rifabutin
Toxoplasma encephalitis (TE)	CD4 <100 cells/mm³ and Positive serology for Toxoplasma (IgG+)	TMP/SMX qd	Dapsone† + pyrimethamine + leucovorin Atovaquone with or without pyrimethamine + leucovorin
Cytomegalovirus (CMV)	Not routinely recommended	NA	NA
Cryptococcus neoformans	Not routinely recommended	NA	NA
Candida sp.	Not routinely recommended	NA	NA

* Formerly Pneumocystis carinii.
† Screen for G6PD deficiency before initiating dapsone.

Table 2: Discontinuation OI Prophylaxis

Pathogen	Discontinuation of Primary Prophylaxis	Discontinuation of Secondary Prophylaxis
Pneumocystis jirovecii pneumonia (PCP)	Patient receiving HAART with increase in CD4 count to >200 cells/mm³ for ≥3 months	CD4 count >200 cells/mm³ for ≥3 months in response to HAART Adequate viral suppression If PCP occurred with CD4 >200 cells/mm³, prophylaxis should be maintained
Toxoplasma encephalitis (TE)*	Patient receiving HAART with increase in CD4 count to >200 cells/mm³ for ≥3 months	CD4 count >200 cells/mm³ for ≥6 months in response to HAART Completed initial therapy Asymptomatic for TE
Mycobacterium avium complex (MAC)	CD4 count increase to >100 cells/mm³ for ≥3 months in response to HAART	CD4 count increase to >100 cells/mm³ for ≥6 months in response to HAART Completed at least 12 months of treatment for disseminated MAC† Asymptomatic for MAC
Cryptococcosis	NA	CD4 count increase to >100 to 200 cells/mm³ for ≥6 months Completed initial therapy Asymptomatic for cryptococcosis
Cytomegalovirus (CMV)	NA	CD4 >100 to 150 cells/mm³ for ≥6 months No evidence of active disease Regular ophthalmic examination

* HIV-infected adults or adolescents with a history of toxoplasmosis in childhood should be administered lifelong prophylaxis to prevent recurrence (AI).
† Obtaining blood cultures or bone marrow cultures may be advisable to ascertain disease activity.